Имя: Bruna Regina Inocente
Возраст: 27 лет
Диагноз: 1. Спиноцебеллярная атаксия 2. Синусовая тахикардия
Дата госпитализации: 22 августа 2016 г.
Длительность лечения: 24 дня
Bruna developed an abnormal gait 5 years ago, she couldn’t walk in a stable manner, and she would often fall down suddenly. Her symptoms progressed slowly. She had a genetic test done at her local hospital 2 years ago and was diagnosed with Spinocebellar Ataxia ACDCA III. She came to our hospital 4 months later, after our treatment, her condition became better, she was able to speak more clearly, she could do the rapid rotation test quickly, the heel-knee-tibia test was performed well, the Romberg’s sign was better improved, she was able to stand on one foot, and she could walk in a straight line. She became pregnant 1 year ago, she had excessive bleeding when she was in labor, and her condition became worse. At present, she has problems balancing on her legs. Her gait is abnormal. She can only walk one single step. She is unable to stand on one foot. She has come to our hospital or a second round of treatment.
She is in good spirits. Her diet and sleep are normal. Her urination is normal. She has bowel movements once in 2 days.
Bp: 103/74mmHg, Hr: 104/min, body temperature: 36.5 degrees. Nutrition status is normal, normal physical development. There is no injury or bleeding spots on her skin or mucosa, no cyanosis, no throat congestion, and there is no swelling in the tonsils. The chest development is normal, the respiratory sounds in both lungs were clear, the breathing sounds in the lower lungs is slightly weak, there was no dry or moist rales. The heart beat was powerful with a regular cardiac rhythm, with no obvious murmur in the valves. The abdomen was soft, with no masses or tenderness. The liver and spleen were normal. There was no edema in the lower limbs.
Bruna was alert and in good spirits. Her speech was not very clear. She had some memory loss, the orientation and calculation ability were normal. Both pupils were equal in size and round, their diameter was 3mm, and reacted well to light. There was no nystagmus. The eyesight and the visual field were normal. The bilateral forehead wrinkles were symmetrical. The chewing ability on both sides was powerful and symmetrical. The nasolabial fold on both sides was equal in depth. The teeth were shown without deflection.. The soft plate could be raised normally. There was slight air leakage when she expanded the cheeks. The tongue was centered in the oral cavity. Bruna could turn her neck and shrug her shoulders powerfully. The muscle power of all 4 limbs was at level 5, the muscle tone was nearly normal. There was hyperreflexia of the bilateral muscle tendon and ankle reflex. The patellar tendon reflex of both sides was hyperactive, the ankle clonus was positive. The bilateral Hoffmann sign was positive; the bilateral Babinski sign was positive. The deep and superficial sensations were normal. The bilateral finger-to- nose test was not very stable or accurate. The fast alternating movements were clumsy. The heel-knee-tibia test was satisfied. The Romberg’s sign was positive. Bruna was not able to stand on one leg. She could not walk in a straight line. The meningeal irritation sign was negative.
Bruna received all the related examinations and was diagnosed with spinocerebellar ataxia. She received 4 neural stem cell injections and 4 mesenchymal stem cell injections to repair her damaged nerves, replace the dead cells with new injected cells, activate the stem cells in her body, regulate her immune system, improve her blood circulation and nourish the neurons. This was accompanied with rehabilitation therapies.
After 24 days of treatment, Bruna’s heart rate is stable, her heart rate decreased to 70-80/min. The balance in all four limbs improved. The arms can rotate much easier and can move in a much bigger range when she performs the fast alternating movement test, the Romberg’s sign is much better than before, when she closes her eyes and doctors push against her body, she can try to control the balance and correct the body posture. She is able to stand on one foot for a short time, her gait is better than before.